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Iorr�� <br /> WORK ORDER #: 04 -FI© - 19VIREI <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT DATE \k— 4 -04 <br /> TEMPERATURE —SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER. LABORATORY(Other than CaIscience Courier) <br /> Chilled, cooler with temperature blank provided 4 ` °C Temperature blank <br /> Chilled cooler without temperature blank 115C IR thermometer <br /> Chilled and placed rn cooler with wet ice Ambient temperature <br /> Ambient and placed in cooler with wet ice <br /> Ambtent temperature <br /> 0 C Temperature blank Initial N-iPl <br /> CUSTODY SEAL INTACT- / <br /> Sample(s) Cooler ✓ No(Not Intact) Not ApplicsWe (NIA) <br /> • Initial <br /> SAMPLE CONDITION <br /> Yes No NIA <br /> Chain-Of-Custody document(s)received with samples <br /> Sample container label(s) consistent with custody papers / <br /> Sample container(s)intact and good condition / <br /> Correct containers for analyses requested <br /> Proper preservation noted on sample label(s) 17-- <br /> VOA vial(s)free of headspace <br /> Tedlar bag(s)free of condensation <br /> Initial <br /> COMMENTS <br />